The present invention, in some embodiments thereof, relates to adjudication platforms and, more specifically, but not exclusively, to methods and systems of identifying additional variables for summaries of multi-aspect adjudication platforms.
Automated and semi-automated adjudication platforms are used in different fields of everyday life, such as banking, actuary and insurance. Banking adjudication platforms may be used to determine customers' commission rates according to variables pertaining to the individual customer, for example overall asset holdings and credit history. In the field of property insurance, adjudication platforms are used to apprise the equitable transfer of the risk of a loss, according to variables such as the situation which led to the damage, monetary value of stolen goods in case of a theft, and/or the like. Adjudication platforms are typically complex, such that decision making in such platforms is performed according to many adjudication platform aspects.
Such multi-aspect adjudication platforms are typically based on a large number of variables, which complicate appraisals of target values such as commission rates in banking or equitable transfer in the field of insurance. Summaries of multi-aspect adjudication platforms, are thereby generated to summarize target values, such that quick appraisal of target values according to a limited number of variables is made possible. Examples of summary types of multi-aspect adjudication platforms include: simplified appraisal tables, text based scenario comparisons, simplified decision trees, simplified benefit rules presentation and/or a combination thereof.
The manual creation of these summaries suffers from several drawbacks. Manual processes are typically slow, costly, error-prone, and difficult to maintain. As policies are renewed, their respective summaries have to be updated accordingly. Previous work demonstrates how, given a set of pre-defined influential variables, summarizing the benefit rules, can be created automatically.
Health insurance policies include a large amount of data of various types and therefore complicated to understand. It is vital for patients to be able to get accurate information regarding coverage provided by their insurance policies. Patients may read through their insurance policy in its entirety, but insurers typically provide shortened summaries of the main sections of each such insurance policy. Such shortened summaries are typically provided in the form of appraisal tables.
Reference is made to FIG. 1, illustrating an exemplary summary table 100 of a pharmaceutical benefit plan, according to some embodiments of the present invention. The pharmaceutical plan yields adjudication target values, such as but not limited to the co-pay result, number of service providers choices such as clinics and/or medical doctors. Each adjudication target value 104 may consist of one or more adjudication aspects, for example the minimal and/or maximal co-pay amount, minimal and/or maximal co-pay percentage from the overall amount paid by an insured member, or the like. The sample refers to two purchase options, also called service types: retail, meaning the drug is purchased at a retail location such as a pharmacy, and mail, meaning that the drug was mailed to the member's address. “Days Supply” refers to the amount of the drug supplied, in terms of the number of days it is supposed to last. The first column 101 applies to a drug purchased in a retail location, in an amount sufficient for at most 30 days. If a larger amount is purchased at a retail location, up to a 60-day supply, the results in the second column 102 apply. Larger amounts are not covered at a retail location. Drugs purchased by mail may include a supply of up to 90 days, and the results displayed in the third column 103 apply. The target values in the table 104 indicate how much a member is to pay for the drug in the given circumstances; this is called the member's co-pay. For example, the value “20%, min $20” indicates the member is to pay 20% of the cost of the drug, but no less than $20 or the actual cost, whichever is lower. Each column of the summary table is called a tier; thus, this policy has three tiers. The number of tiers in each table may vary according to the details of the policy. For example, a 4-tier policy could distinguish between Formulary Generic, Formulary Brand, Non-formulary Generic and Non-formulary Brand tiers. Other policies may have additional tiers for specific groups of drugs; common examples are specialty drugs, high cost drugs, and drugs consumed by means of injection. An exemplary policy having a single tier is called “All”. We note that this could be just one part of a larger summary, which may include details such as but not limited to which drugs are covered by an insurance policy and which are not. The specific exemplary example of a “co-pay summary” table in FIG. 1 is one of the more complex parts of the summary which may be extracted from the code which implements the adjudication platform rules.